Allergic Rhinitis Management
Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis and should be your initial therapy for patients with moderate to severe symptoms that affect quality of life. 1, 2, 3, 4
Treatment Algorithm Based on Severity
Mild Intermittent Symptoms (< 4 days/week or < 4 weeks/year)
- Start with second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) OR intranasal antihistamines (azelastine, olopatadine) 4, 5
- These agents work best for sneezing, itching, and rhinorrhea 6
- Avoid first-generation antihistamines due to sedation, impaired work performance, and increased accident risk 3
Moderate to Severe or Persistent Symptoms (> 4 days/week and > 4 weeks/year)
- Initiate intranasal corticosteroids immediately (fluticasone, triamcinolone, budesonide, mometasone) 1, 2, 3, 4
- Critical counseling point: Direct spray away from nasal septum to prevent bleeding and irritation; maximum efficacy requires several days of consistent use 3
- For seasonal allergic rhinitis, start medication BEFORE the season begins for optimal prophylaxis 6
Combination Therapy for Inadequate Response
If monotherapy fails, add intranasal antihistamine to intranasal corticosteroid - this combination provides greater efficacy than either agent alone 1, 2, 3
Additional options for specific symptoms:
- For severe rhinorrhea: Add ipratropium bromide intranasal spray to intranasal corticosteroid (more effective than either alone) 1
- For nasal congestion: Consider short-term oral decongestants, but screen carefully for contraindications (hypertension, anxiety, cardiac disease) 3
Environmental Control Measures
Identify specific allergens through testing, then implement targeted avoidance strategies 6, 2
- For animal allergies, complete avoidance is most effective 6
- Address non-allergen irritants: tobacco smoke, strong odors, temperature/humidity extremes 6
- Recommend nasal saline irrigation as adjunctive therapy to clear secretions and relieve congestion 3
Allergen Immunotherapy
Offer immunotherapy to patients with documented specific IgE antibodies to clinically relevant allergens who fail pharmacotherapy with or without environmental controls 1, 2
- This is the only treatment that modifies the natural history of allergic rhinitis with sustained benefits after discontinuation 2
- Requires poor response to optimal medical management before consideration 6
Rescue Therapy for Severe Exacerbations
A short 5-7 day course of oral corticosteroids may be appropriate only for very severe, intractable symptoms or significant nasal polyposis 2, 3
Critical Pitfalls to Avoid
- Never use topical nasal decongestants beyond 3-5 days - causes rebound congestion (rhinitis medicamentosa) 2, 3
- Do not prescribe recurrent parenteral corticosteroids - contraindicated due to systemic adverse effects 2
- Avoid antibiotics - they are ineffective for allergic conditions and promote antimicrobial resistance 3
- Never rely on IgE testing alone - positive tests must correlate with clinical symptoms and allergen exposure history to be clinically meaningful 2
- In children under 3 years, avoid decongestants and antihistamines due to adverse effects outweighing benefits 3
- In elderly patients, exercise extreme caution with first-generation antihistamines due to increased psychomotor impairment and anticholinergic effects 3
When to Refer to Allergist
Refer when symptoms remain inadequately controlled despite optimal pharmacotherapy, or when immunotherapy consideration is needed 2